Introduction

Overview

A. Incise Skin and Dissect Down to Fascia

B. Place Fascial Stay Suture and Open Fascia and Peritoneum

C. Sweep any Abdominal Structures Away From Port Site with Finger Sweep

D. Place Umbilical Port

1. Placement of Umbilical Port

A. General Inspection

B. Identify any Peritoneal Adhesions

C. Placement of Lateral Ports Under Direct Vision via Umbilical Port

2. Inspection of Abdominal Contents

A. Identification of Stomach and Greater Omentum

B. Mobilization of Greater Omentum and Entry into Lesser Sac

C. Identification of Mass

3. Identification and Mobilization

4. Excision of Mass

5. Lysis of Adhesions

A. Removal of Specimen via Endo-catch Bag

B. Inspection of Abdominal Contents and Gastric Staple Line

C. Fascial Closure

D. Infiltration of Local Anesthetic

6. Closure

The stomach is involved in multiple common ailments, including gastroesophageal reflux disease, gastric ulcers and cancer, the latter of which can take many forms. One cancer that presents a management challenge is gastrointestinal stromal tumors, or GIST tumors for short. Originally, these are tumors that arise from the connective tissue, or stroma, of the stomach, rather than the lining, from which the more common and more deadly gastric adenocarcinoma finds its origin. However, over time, study revealed that GIST arises from a very specific cell, called the interstitial cells of Cajal, that are responsible for the timing of contraction in the stomach and small intestine. GIST masses generally behave more indolently than gastric adenocarcinoma, with distant or lymph node metastases a rare feature, although involvement of the liver and peritoneum has been described. Due to this indolent nature, certain masses, once they have been identified as GIST through endoscopic biopsy, are candidates for surveillance. However, larger masses (as identified through evidence of necrosis on imaging) and rapidly growing masses are treated primarily with surgical resection. While in the past surgical resection would have involved a large abdominal incision and a lengthy postoperative recovery, laparascopic techniques have allowed gastric resection to become a short procedure necessitating only an overnight stay.

Identification of stomach and greater omentum

Mobilization of greater omentum and entry into lesser sac

<h4>CHAPTER 1</h4>

<p>So she had a previous tram flap. So we’ve got to be careful. Right I guess. Yea, but you’re off the midline. You want to stay off the midline or come. Yeah midline should be okay. I would go like there. You have a hemostat? Two army-navys and two kochers. Umbilical cord is our visual course. It’s what we do if most of these laparoscopic cases...There you go. This is the fascia. Let’s get her stitch in there. One on each side. It’s kind of, right there. There it is. You’re in. So in this situation, you always do direct placement? I always do direct, with all of them. Put the gas on, please. Okay. Okay. So I usually, use a 30 degree scope for these. Forty-five is fine. Do you want, is that okay? Nope, that’s fine. </p>

<h4>CHAPTER 2</h4>

<p>Yea, so this is... That’s stomach down there…  Liver, falciform, gallbladder. Yea it was huge on the CAT scan. Let’s take a quick look around. Yea, looks like a nice adhesion. Hernia in the making or a bowel obstruction in the making, you know? Is that the normal incision? Yea, she had a tram flaps and then with a tummy tuck with it. So this could be if they could into the, you know over here, they probably got in a little bit. You can usually get into the abdomen with the tram flaps? Yea, we’ll be careful to take that down. </p>

<p>So where do you want to put your ports? So you’re going to want, the 12 inch here with a stapler. And then probably 2 here? I would probably do it the way we normally do with the spleens. I would probably put one here and two here. This way it’s more like the triangular area. So flap over here, and then 12 and 5? Yea so we’ll put a 5 here for retraction, a 12 here for the stapler and ligature and then another 5, way lateral over here for the retraction. Because I’ll be able to triangulate up for the thing where the tumor is. </p>

<p>So let’s put these in first. Let’s see where this thing is, down here. Is that it? So this should be good. Over here anyway. Because then you can work downwards. What’s that one? Is that anything we should take down? We could. That’s easy.  Can I get the patient in some reverse? That’s good. Thanks. Let’s look at the stomach again. I just want to see where we are at. Yup. Right over here. Might be too low. I think this is better. Do you have the knife? Fifteen blade? I know I made my skin incision big enough, maybe not. Do you have a fifteen blade again? There we go. Can I have the five, please? So now, I would probably go higher. But should we be on, probably want to be over here so we're not going through the falciform. Blade again. See that fifteen two? Think you arein. You just… go past the falciform though. Yeah, I can get under that.</p>

<h4>CHAPTER 3</h4>

<p>Can I have a grasper, too? Pull the omentum down. Carefully, comb this way, I would rotate it, yeah, that way. Why is this stuck up here? What if I… so this omentum is stuck. Just got to take that down. So that goes up. That’s all lesser omentum. See? I thought that was greater omentum. Can I have another grasper, please? Would you like the endoshears? No, we’re okay. Grab the stomach, pull it towards you. It’s on the posterior greater curve, up high. That’s it probably, right here. Alright, relax a second. Let me just see... I can’t pull any farther than that, that’s as far as it it will go in. Just want to see the, yes, it’s going to be right here. So that’s spleen, there. Think it’s going to be right over here. So I would, let’s just take the shorties down. Okay. </p>

<p>Can these masses ever be benign? Can they be like mild myeloma? Yea, well it’s a GIST tumor, which is what it is, they’ll, they have a high propensity to, depending on the size and how many mitotic figures there are, they can metastasize. The problem is you can't, you don't know if something's malignant or not, until it actually already is has gone somewhere. So you watch to see if they've gotten bigger. So is there a goal for watching certain types of gastric masses?
You can if they're small. And her, her’s was small to begin with, like one and a half centimeters.And then it got bigger and this biopsy came back that it was a GIST. Just go right there.  Closer and closer to me, a little bit. So you know most patients go on Gleevec afterwards if they're higher risk, just to prevent it from coming back or if it is a malignant form, because it came out.</p>

<p>You just want to make sure we take the short gastrics, not the gastroepiploic here. Well you buzzed down here. Why don’t you see if you can get that spot a little bit. There you go. So we’re just taking the short gastrics down now. Okay. Let me do this a second. Is that it? That’s the NG tube. NG tube. Nice thought, but nope. You can get closer to the stomach if you want. Might actually have to grab the stomach. Let’s grab the stomach itself. There you go, pull it towards us. Good. You can get closer to the stomach again. Yea this is why I want you to pick the other one because this one is going to take forever. </p>

<p>So I think this is tattooed, also. So we should be able to see, some blue, which is good. So starting to see the blue here from where they tattooed the tumor. Oh they tattoo it! Yea. Otherwise it can be difficult to find it. Yea, sometimes it’s easy. Sometimes it’s not. Her’s is around 2.5 cm. About an inch. So that could potentially be a little bit difficult. So how do they, do the GI people tattoo it? Yea. Yeah. If we could stay closer to the edge than we could just take-Avoid all that fat. Get a little closer to the stomach, if you can. You need to have more traction so I would...Careful not to rip it. I know I said more tension, but you know what I mean. So I would be closer to the stomach, right where the clear stuff is. Down there more? Yea. Is she alright? Yea. It’s because her BP cuff is on the same side. </p>

<p>So I would be okay grabbing that, because you’ve already, you already ligatured that stuff, right? Right so if you grab that you can wind up tearing it. Let me regrab it for you. Keep pulling down towards the feet. Let me regrab now. If you do it twice in the same place, it... yea. Alright let’s see, what we got going on here. Of course I don’t feel it. Let’s keep going. You got it? Seemed too low. So we got to be way up by the spleen. Sorry. Back up and you see that little, thing there? Right there? No, this. That’s is right there. Yep. So angle it so you, like your, you with your left hand. You can angle so you can adjust it to where the angle of that is.  Pull on that. 
Okay let’s see what we got here. Still can’t get it too good. Sticky. Alright. Let’s see if you can get that. Alright, good. I’m letting go in a second. So what are we stuck on? Nothing. This little stalk there. On this tumor, do you have to be very careful in terms of tumor spillage and all that? Yea you don’t want to. Because they actually will, seed it. </p>

<h4>CHAPTER 4</h4>

<p>So we’re just debating what size stapler we want to use. We want the appropriate thickness but not too thick because then it’ll bleed. Now can you just staple across and that’s the end of that? That’s all we’re doing. That’s a wedge resection of the stomach. Yea, I mean we should be able to. I would use a purple. This a reticulate? Yea it does actually. Oh, good. Yep, I see the other side of it. Do you need to have a certain margin on it? You just have to have a margin really. I’d rather you get a little closer. Turn the other way, flip it, turn it towards you little bit. That should be good. Go ahead. Whoops. You’re over there. Sorry I’m not holding it. </p>

<h4>CHAPTER 5</h4>

<p>Should leave that there. Go for this thing. Two for one. Going to get the adhesion. So you’re working this way. There’s a stitch there. Yea just cut it out a little bit.  That might be hard. Let’s see. See how that’s wrapping around there. Yea that’s definitely like, like a...Just be careful. Just be careful don’t push too, don’t push in like that. Just push down. Yea. Give yourself more tension. Get a little closer to the, here let go. Get a bit higher up, can you get higher up and get a good bite. Lower. I think it's lower than that. Right there? Yea I think so. I think because we’ve taken maybe some peritoneum out it’s going to be a little more harder. Get tension. Definitely need more tension on that if you can. Grab it like you mean it. Higher up if you can. If you can’t, you can’t. Get a good bite. Grasp it. Keep pulling down. You want to cut it too. There you go. That’s the spot. </p>

<p>What’s going on there? Yea, stay up high. There you go. Nice. I think you’re safe there. I could be wrong. Famous last words. I don’t think that’s the ureter. You might need to regrab or do something else with your other hands. Help yourself out. Let’s see the back of it, a second. Should be a little just cutting. Stay up high, stay up high and cut. Full thickness. Just do it. Right before you let go, let’s take a peek. Can I have another grasper, please? Grab the distal end or the proximal end, whichever one that is and pull it towards us. Rub on it, so you can see if it’s serosal or muscle or whatever.  I think that’s fine actually. We’re okay. I’d leave it alone. </p>
 
<h4>CHAPTER 6</h4>

<p>No, the endo-catch bag. The blue, if you can. The staple line. Alright, so let’s look at all the trocars. Remember, you can turn it, so you can… oh geez. Alright let’s just, I want to see the staple line one more time too. I’ll take another grasper, please? There it is. Okay, this looks good. No more bleeding. Let’s take that sucker out. Can you shut everything off please? Scissors please? There it is. Here’s the fascia fat. Here’s the fascia down there. So all that, big bite that way. See there’s that and that back stuff there. That feels pretty good. Okay. Do you have local? Here’s the needle. Thank you. </p>



Tufts University School of Medicine

Laparoscopic Gastric Wedge Resection

0066GoodmanPre9.24.14

0066 - Goodman

The stomach is involved in multiple common ailments, including gastroesophageal reflux disease, gastric ulcers and cancer, the latter of which can take many forms. One cancer that presents a management challenge is gastrointestinal stromal tumors, or GIST tumors for short. Originally, these are tumo...

Laparoscopic Gastric Wedge Resection | Journal of Medical Insight

DOI
Publication Date	N/A
Article ID	11
Production ID	0066
Volume	N/A
Issue	11
https://doi.org/10.24296/jomi/11

Laparoscopic Gastric Wedge Resection

Procedure Outline

Table of Contents

Port placement (Umbilical port)

Inspection of abdominal contents

Placement of lateral ports

Identification of stomach and greater omentum

Mobilization of greater omentum and entry into lesser sac

Identification of mass

Excision of mass

Lysis of adhesions

Closure